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Oncology - Superior Vena Cava Syndrome - Fast Facts | NEJM Resident 360
Superior vena cava (SVC) syndrome results from obstruction of the SVC. The most common malignant causes of SVC syndrome are non–small-cell lung cancer, small-cell lung cancer, lymphoma, and metastatic lesions. Propagated thrombosis around a central line should also be considered.
Decreased venous return (secondary to compression of the SVC, right side of the heart, or both) may result in hemodynamic compromise. While presentation of SVC syndrome can be impressive, it is rarely an emergency. Many cases have a relatively benign course, and some patients may even improve without therapy. Treatment of SVC syndrome is twofold: management of symptoms and management of the malignancy.
Etiologies of SVC Syndrome
(Source: Superior Vena Cava Syndrome. J Am Coll Cardiol Intv 2020.)
Presenting Signs and Symptoms
Patients with SVC syndrome present with edema of the head, neck, and arms, often with cyanosis, and distended subcutaneous vessels. SVC syndrome may cause the following signs and symptoms:
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cough
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hoarseness
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dyspnea
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stridor
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headache
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confusion
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coma
The following table lists other symptoms of SVC syndrome and their frequency:
Physical Exam Findings
(Source: Superior Vena Cava Syndrome with Malignant Causes. N Engl J Med 2007.)
Grading of SVC Syndrome
(Source: Superior Vena Cava Syndrome. J Am Coll Cardiol Intv 2020.)
Treatment
Symptomatic treatment of SVC syndrome:
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raise the head of the bed
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dexamethasone (4 mg every 6 hours), although benefit is unclear
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supplemental oxygen for dyspnea
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if airway compromise, call anesthesia and surgery
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placement of intravascular stent (can be done to relieve symptoms before tissue diagnosis is known, but only if the patient is very symptomatic)
Treatment of malignancy: Patients require radiation therapy or chemotherapy (small-cell lung cancer and lymphoma are very chemosensitive). Tissue diagnosis is needed prior to radiation therapy and should be done in an urgent manner (especially in the presence of airway compromise) with rushed pathology.
The following chart shows a proposed algorithm for treating malignant causes of SVC syndrome:
Management Algorithm for Malignant SVC Syndrome
The following table compares treatment options for malignant SVC syndrome: